It’s a rare individual who has never had a nosebleed. The nose has many tiny blood vessels, most located in the cartilage-bearing nasal septum (the wall between the nostrils). Unlike the eyes, which are protected by being recessed into the skull, the nose protrudes from the face, leaving it vulnerable to injury.

About 90% of the time, nosebleeds (also called “epistaxis”) originate in the front of the nose (“anterior”) near the septum. This location, known as “Little’s Area” or “Kiesselbach’s Plexus” contains numerous small arteries and veins where bleeding can originate. Anterior bleeding comes from one nostril only in the grand majority of cases.

In a small percentage of cases, bleeding starts in back of the nose (“posterior”) where other arteries are located. These nosebleeds have a tendency to occur more often in the elderly, be heavier in volume, and more difficult to stop. A posterior nosebleed may be suspected if you see heavy bleeding from both nostrils or blood draining down the back of the throat.

Nosebleeds can, of course, occur from trauma to the face. They can also be caused by factors that affect the inside of the nose, such as excessive “picking” or irritation from upper respiratory infections. Environmental factors such as particularly cold or dry climates may also play a role, as can medications that prevent clotting. In unusual cases, underlying illness (such as high blood pressure), pregnancy, or small tumors may be implicated as the cause.

Deaths due to nosebleeds are very rare, but bleeding can be significant. Still, most can be handled successfully with limited supplies in an austere environment.

To stop a nosebleed:

1. Keep the patient calm. Anxiety will speed the pulse and cause more rapid bleeding.
2. Sit the patient upright with the head tipped slightly forward. You may have been taught to tilt the head backward, but this causes the blood to run down the back of the throat. Have them breathe through the mouth.
3. Spit out blood in the mouth and throat instead of swallowing it. Blood can irritate the stomach.
4. Using the thumb and index finger, firmly pinch the soft part of the nose just below the bone and press towards the face. Apply pressure for 5-10 minutes. Be patient.
5. Apply an ice pack to the affected side. Cold constricts blood vessels and may help stop the bleeding.
6. Check to see if your patient’s nose is still bleeding after 10 minutes. If still bleeding, sniff in or blow out accumulated blood once and, then, hold the nose for 10 more minutes.
7. Nasal spray oxymetazoline (generic Afrin) will also help stop the bleed, but beware of elevating blood pressure.
8. If the bleeding successfully stops, the patient should try not to blow their nose, bend over, or strain for the next day.

A dental cotton roll folded in half (with petroleum jelly or Afrin, if available) on a clamp (see image) may be placed in the nasal cavity to stop bleeding with some external pressure. Pinch the nose for 5-10 minutes while the head is tipped forward. Once bleeding has ceased, carefully and slowly remove the clamped dental roll.

Placing A Nasal Pack

If the above procedure fails to stop bleeding, a packing with petroleum jelly may be required to apply pressure to the leaking vessel. Other materials, like BleedCEASE or NasalCease, contain blood-clotting agents which can be fashioned into a packing.

To place a simple packing into the nose, strips of gauze impregnated with petroleum jelly is gripped with a “bayonet” forceps, Kelly clamp, or blunt tweezers and inserted into the anterior nasal cavity.  The first packing layer is inserted straight back along the floor of the anterior nasal cavity (not at an upward angle). A small instrument called a “nasal speculum” may be used to open the nostril for a better view.

Additional layers of packing are then added in accordion-fold fashion. The nasal speculum can be used to hold layers down as new ones are inserted.  Packing is continued until the nasal cavity is filled. Be aware that you could traumatize the nasal cavity if placement is poorly performed.

It should be noted that nasal packing can be very uncomfortable. Significant pressure is usually required to be effective and the packing must stay in place for a good 48 hours or so.

In stubborn cases, carefully place BleedCEASE, Nasalcease, or other hemostatic dressing  in the nostril with a blunt tweezers or curved Kelly clamp. If using a longer strip, be sure to leave a small piece outside. Then, apply external pressure by pinching the bridge of the nose for 5-10 minutes. Hemostatic gauzes can be left in place for up to 24 hours. If they dry out, moisten before removing with some water or saline nasal spray from a 12 cc or bulb syringe.

Alternatively, the bleeding nostril can be flushed with sterile saline; then, gently introduce a thin strip of cloth drenched in oxymetazoline (Afrin) or epinephrine (from an Epi-pen or other anaphylactic shock kit) and pack gently into the nostril. Apply external pressure for 5-10 minutes and don’t remove the packing for several hours. Avoid blowing the nose to eject clots, as it may restart the bleeding, regardless of the origin.

A natural hemostatic agent is geranium oil. A few drops on a strip of gauze could be placed in the bleeding nostril with good results in many cases. Yarrow is another time-honored option. Crush the leaves between the fingers and insert them into the nostril. Leave in place until the bleeding stops and then remove. Don’t forget to apply external pressure as described above.

A true posterior bleed may be difficult to stop without expensive balloon catheters such as the Rhino-Rocket, the Epistat catheter, or the Simpson Plug. A urinary Foley catheter with a filled balloon (add sterile water to the balloon after placement) may also be an option. All of these options help increase pressure further back along the nasal cavity.

Once you’ve had a significant nosebleed, you’ll do everything possible to not have another. Here are some strategies that will decrease the chances of a recurrence. One basic strategy is to prevent nasal dryness. This can be achieved in a number of ways:

• Apply petroleum jelly. In patients with frequent nosebleeds, chronic irritation of the walls of the nostril may be the problem. Protect this area by applying small amounts of petroleum jelly gently inside the nose, especially before going to sleep. Admonish children to avoid “picking” their nose. Keep fingernails of both children and adults well-trimmed.
• Use sterile saline nose drops during the day to keep nasal passages moist. Simply mix one teaspoon of salt into a quart of clean water, boil for 20 minutes, and let cool before flushing each nostril.
• If you have electricity, use a humidifier, especially in the bedroom at night. Those who use tobacco and suffer from nosebleeds should know that smoking dries out and irritates the nasal lining.

Other strategies that decrease the frequency of nosebleeds include:

• abstaining from blowing your nose forcefully.
• avoiding excessive use of decongestants.
• monitoring the use of aspirin or alcohol.

Nosebleeds may be a minor occurrence, but can present a lot of anxiety for the patient and    headaches for the family medic. Keep nasal passages moist and, just a thought, you might consider avoiding those bar fights you’re always getting into (just kidding)!

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Joe Alton MD

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